Advances in immunosuppression for pancreas transplantation

Purpose of review A review of current literature was performed to identify trends and evaluate outcomes with regard to clinical immunosuppression in pancreas transplantation. Recent findings Through 2006, over 20 000 pancreas transplantations were performed in the US. Since 2000, the 1-year patient survival rates for the three pancreas transplantation categories - simultaneous pancreas-kidney, sequential pancreas after kidney, and pancreas alone - were 95-97% and the 1-year pancreas graft survival (complete insulin independence) rates were 85%, 78%, and 77%, respectively. One-year rates of rejection have steadily decreased and are currently in the 10-20% range depending on case mix and immunosuppressive regimen. At present, 88% of recipients receive antibody induction, 65% receive maintenance therapy with the tacrolimus/mycophenolate mofetil combination, and 40-50% undergo corticosteroid withdrawal without adverse consequences. Limited data with tacrolimus/sirolimus reveal excellent short-term outcomes, whereas initial attempts with calcineurin inhibitor avoidance or minimization are less promising. Summary Antibody induction and either tacrolimus/mycophenolate mofetil or tacrolimus/sirolimus maintenance therapy with steroid withdrawal have become the mainstay of contemporary immunosuppression in clinical pancreas transplantation. The development of a nonnephrotoxic, nondiabetogenic, and nongastrointestinal toxic regimen, however, is highly desirable to improve outcomes and quality of life in recipients.